School Mental Health Program

Intake and Treatment Form

I. General Background

Student Name:______Gender: M F

Address:______

Telephone:______

Date of Birth:______Age:_____ Grade:____

Referral Source:______

Reason for Referral:______

How long has the behavior/issue been a concern:______

Guardian:______

Who lives at home with you?

Guardian:______Natural Parent Foster Step Adoptive Other

Other Family Members in the home:

Name:______Age:______Sex: M F Relation:______

Involvement with parent if he/she does not reside in the home? Y N

Amount of time spent:______Types of Activites:______

______

Have there been any out of home placements or CPS involvement: Y N Describe______

______

II. Guardian Background

Name:______Highest Level of Education Completed:______

Current Employment:______

Home Schedule:______

Name:______Highest Level of Education Completed:______

Current Employment:______

Home Schedule:______

III. Child & Family Medical and Psychiatric History

Does the child have any current health problems: Y N List (Sickle cell, diabetes, lead, asthma, etc.):

______

Is the child currently on any medications: Y N List______

______

Reason prescribed:______

Prescriber:______Duration:______Compliant: Y N

How does it affect behavior (sleepy, drowsy, loss of appetite, etc.):______

______

Past Medications: Y N List______

Past Hospitalizations: Y N List______

Any ER episodes: Y N List______

______

How is the child’s current health:______

______

Does the child have any problems with: Hearing:Y N Vision: Y N Speech: Y N

Describe:______

Name of Pediatrician:______Date of last visit:______

Has the child received mental health services before: Y N Describe

______

Any current health conditions in the family: Y N List______

______

Any medical conditions that run in the family (diabetes, thyroid, cancer, etc.): Y N

List______

Are there any psychiatric conditions that run in the family (anxiety, depression, bipolar, etc.) Y N List______

______

Is there a history of substance abuse in the family: Y N Describe______

______

Has anyone in the family received counseling services: Y N Describe______

______

Do any other children in the family have emotional or behavioral problems: Y N List______

Does anyone in the child’s household use tobacco: Y N Describe:______

Has the child ever used tobacco: Y N If so, please report length of time and current frequency______

If answer yes to above question, please review potential risks associated with using tobacco products. Risks reviewed: Y N

IV. Developmental History

Complications during pregnancy or delivery: Y N Describe______

______

At what age did the child first: talk ______crawl ______walk ______toilet trained ______

V. Child Behavioral and Emotional History

Describe a typical day for the child:______

______

What time does the childgo to bed ______get up______

How often is the child disciplined:______

Who usually disciplines the child:______

How is the child disciplined/punished at home:______

Which form of discipline has been found to be most effective:______

Aggressive Behaviors (fighting, vandalism, animal cruelty, intimidates, threatens, use of weapons, stealing, fire setting):______

______

Has the child had any legal difficulties: Y N Describe______

______

How does the child get along with guardian/s:______

How does the child get along with other family members in the home (siblings):______

______

How do other family members relate to one another:______

How is affection expressed in the family:______

Who provides the child with support and guidance:______

Spirituality/Religious Involvement:______

Has the child experienced any traumatic event (death in the family, abuse, violence in the neighborhood):

Y N Describe______

______

Has anyone in the family had problems similar to those of the child: Y N Describe______

______

VI. Academic and Social History

Past schools attended:______

Years at CurrentSchool:______Special Education History: Y N

How does the child get along with school staff:______

How does the child get along with school peers:______

______

Academic Performance (Grades):______

Strongest Subject/Weakest Subject:______

School Involvements:______

Attendance:______Disciplinarian Encounters:______

Classroom Behavior:______

______

Describe the child’s relationships (friendships, dating):______

______

List hobbies, activities, interests:______

______

Neighborhood Description:______

______

VII. Mental Status and Clinical Presentation

Appearance: Well-groomed Standard Disheveled

Depression: Sleeping habits:______

Appetite:______

Energy level:______

Concentration:______

Interest Level:______

Sadness:______

Suicidal Ideation(Past): Y N Describe______

Suicidal Ideation(Present): Y N Describe (Plan, Means, Intent)______

Anxiety(worries, fears, phobias):______

______

Obsessions and Compulsions(repetitive behaviors, persistent thoughts): Y N Describe______

Substance Use: Y N Describe______

______

Homicidal Ideation (Past): Y N Describe______

Homicidal ideation (Present): Y N Describe______

Other Symptoms and Concerns:______

______

VIII. Student’s Perceptions and Strengths

How does the child think counseling can be helpful:______

______

List 3 things the child can do well:______

In their own words have the child describe him/her self:______

______

Future goals:______

IX. DIAGNOSIS: DSM IV

Axis I:______Axis IV:______

Axis II:______GAF:______

Axis III:______

X. Treatment Plan:

ProblemObjective:Approach:

1.______

______

2.______

______

3.______

______

Reviewed with student: Y N

CounselorDate